The hyperplasia begins in the prostate tissue around the urethra and then progresses to compress the remaining gland. The tissue becomes nodular, comprising of smooth muscle, stroma and glandular epithelium. The precise reason for the proliferation of the glandular epithelium is not known, however, the involvement of Androgen (testosterone and other male hormones) estrogens and other growth factors have been postulated.
The prostate lies between the bladder (
and surrounds the urethra) and the rectum, therefore, the
enlargement can obstruct urinary outflow causing urinary retention or
obstruct the rectum causing constipation and consequently, may be
associated with abdominal pain.
Symptoms Of Benign Prostatic Hyperplasia
Benign Prostatic Hyperplasia causes both obstructive and irritative symptoms. Obstructive symptoms are related to the mechanical obstruction of the urethra by the enlarged prostate (intially, the bladder tries to overcome the obstruction by undergoing a compensatory hypertrophy), while irritative symptoms result from contraction of the bladder detrusor muscle. Both symptoms are associated together, 50 percent of the times. Sometimes, an individual may have BPH without any symptoms.
Obstructive Symptoms:
The obstructive symptoms include:
hesitancy ( difficulty in initiating the flow of urine),
diminished force of urinary stream (despite a full bladder), feeling
of incomplete bladder emptying ( patient feels that there is
still some residual urine), intermittent urinary stream,
straining to urinate, Post-urination urinary dribbling ( ranging from
a couple of drops after urination to a continuous leak that is
difficult to control) and urinary retention ( this
retention may occur suddenly or over a period of time).
Irritative Symptoms:
The irritative symptoms
include: daytime frequency, nocturia (awakening from sleep to pass urine at night), dysuria
(painful or difficult urination), urgency (sudden, compelling urge to urinate
that brooks no delay), and overflow or urge incontinence ( an urgent need to
urinate that may be associated with leakage of urine).
If the condition becomes complicated, there may be
hematuria (presence of blood in the urine) due to congestion and rupture of the superficial veins of the prostatic urethra.
Straining to urinate may eventually lead to syncope (vasovagal), inguinal hernias.
Other symptoms may also include abdominal discomfort and urinary retention.
Urinary retention can either be chronic ( developing over time) or acute (
occurring suddenly). Acute urinary retention can be precipitated by infections,
alcohol, anesthetics, exposure to cold or use of antihistamines.
Management Of Benign Prostatic Hyperplasia
Diagnosis Of BPH
Diagnosis of the condition is based principally on digital rectal examination and
the symptoms that the patient present with. Digital rectal
examination may reveal an enlarged prostate with or without a
palpable bladder. The natural history of the condition is not often
clear cut and a majority of men with BPH do not present with either
significant obstructive or irritative symptoms, and an enlargement
of the prostate alone is not always a valid reason to treat the affected
individual.
The
attending health practitioner will take a detailed history, focusing
on the urinary tract, making every effort to identify or rule-out
other possible causes of urinary voiding dysfunction. The
practitioner may quantify the disorder ( as either mild, moderate,
or severe) based on AUA Symptom index ( which is also used in
planning treatment and patient follow-up). Prostate-specific antigen
( PSA) may be measured and used for exclusion of advanced cases on
prostate cancer. PSA is not particularly useful in early case of
Prostate cancer. Other tests that may be carried out include
uroflowmetry, postvoid residual urine volume, pressure-flow studies,
urethrocystoscopy and imaging studies such as ultrasonography and
intravenous pyelography. The health practitioner will determine
which is appropriate.
Treatment Of BPH
Patients who have benign prostatic
hyperplasia but do not have any symptom, are generally not placed on
any
treatment. A variety of decision diagrams are available to assist
health practitioners in making decisions as to what kind of action
is applicable, but ultimately, the decision to treat and the
appropriate treatment depends on the severity ( and type) of the
symptoms and affected individual's expectations and preparedness to
accept the adverse consequences of treatment
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Lifestyle Modification:
Affected individuals are advised to decrease fluid intake before bedtime,
reduce consumption of alcohol or caffeinated beverages.
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Watchful Waiting:
This approach is for
individuals who do not have symptoms. But these individuals
must be monitored annually for evidence of disease
progression. |
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Before engaging in any form of medical or
surgical intervention for BPH, the health practitioner
will perform the following: Take a complete history, perform
a thorough physical examination which includes a digital
rectal examination, ultrasound, routine urine analysis,
electrolyte check, determination of post-voidal residual
urine, cystoscopy and PSA determination. |
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Medical Treatment :
Medical treatment is targeted
towards relaxing the prostatic smooth muscles ( by
inhibiting the alpha adrenergic receptors) and suppression
of the hormones. Fenastride is the most promising of the
anti-androgenic drugs that are currently in use. This drug
inhibits 5-alpha reductase enzyme and thereby blocking the
conversion of testosterone to dihydrotestosterone. It has
been shown to reduce the prostate size by about 24 percent,
the PSA levels and consequently an improvement in the
symptoms. Terazosin has been effectively used to relax
the smooth muscle of the bladder neck and therefore
increased urinary flow rate. Not all affected individuals
respond to medical treatment and the drugs also have their
own side effects which we will not discuss here. |
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Surgery:
Prostate surgery provides the
best chance of improvement in symptoms, but it also comes
with possible complications. In general, transurethral
resection of the prostate is the most common surgical method
in use. This the ideal procedure used for patients with
relatively small prostates. Open prostatectomy is used on
affected individuals with huge prostate. Open prostatectomy
has high complication rates.
Other methods of treatment
such as laser surgery., thermal therapy and stents are also
being evaluated for efficacy. But the health practitioner
will make the decision as to which line of action is
appropriate for you. Be sure to consult your doctor for
clarification. |
References
http://www.merck.com/mmpe/sec17/ch240/ch240b.html
Benign prostatic hyperplasia - From Wikipedia, the free encyclopedia Retrieved on 103009
Bent S, Kane C, Shinohara K, et. al. Saw palmetto for benign prostatic hyperplasia. NEJM . 2006; 354:557-566.
Wilt, T.J., et al. Saw Palmetto extracts for treatments of benign prostatic hyperplasia. Journal of the American Medical Association 1998; 280: 160-9
